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Submitting a Request for Anticipated Payment (RAP) under the Home Health Patient-Driven Groupings Model

The home health Patient-Driven Groupings Model (PDGM) was effective for RAPs with a "From" date on or after January 1, 2020, as described in the Calendar Year (CY) 2019 home health (HH) final rule (CMS-1689-FCExternal Website). This changed the payment from 60-day episodes of care to 30-day periods of care. The following information includes details about changes to RAPs in CY 2021, and the data elements needed when entering a RAP using the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE). Refer to MM11855 – Penalty for Delayed Request for Anticipated Payment (RAP) Submission – ImplementationExternal PDF for information CY 2021 changes.

When to Submit a RAP

RAPs are submitted at the beginning of each 30-day period. Home health agencies (HHAs) newly enrolled in Medicare on or after January 1, 2019, shall submit a no-pay RAP at the beginning of each 30-day period.

Starting in CY 2021, all HHAs (newly-enrolled and existing) will be required to submit a RAP at the beginning of each 30-day period of care. When multiple 30-day periods of care are ordered based on the plan of care, HHAs may submit both the RAP for the first 30-day period of care and the RAP for the second 30-day period of care (for a 60-day certification) at the same time. 

RAPs are submitted when:

  • The appropriate physician's written or verbal order that sets out the services required for the initial visit has been received and documented as required; and
  • The initial visit within the 60-day certification period has been made and the individual is admitted to home health care.

Untimely Submission of RAPs (Effective January 1, 2021)

Starting in CY 2021, a payment reduction will apply when the HHA does not submit the RAP within 5 calendar days from the start of care date ("admission date" and "from date" on the claim will match the start of care date) for the first 30-day period of care in a 60-day certification period, and within 5 calendar days of the "from date" for the second 30-day period of care in the 60-day certification period. The payment reduction will be equal to a 1/30th reduction to the 30-day period payment amount for each day from the home health start of care date/admission date, or "from date" for subsequent 30-day periods, until the date the HHA submits the RAP.

Low Utilization Payment Adjustments (LUPA)

An HHA may decide not to submit a RAP if they know in advance that the period of care will result in a no-RAP LUPA. However, under PDGM, LUPA thresholds range between 2 and 6 visits; therefore, it is more challenging to predict when a period of care results in a LUPA. Effective January 1, 2021, if a RAP is submitted and is untimely, no LUPA per-visit payments would be made for visits that occurred on days that fall within the period of care prior to the submission of the RAP. However, if a RAP is not submitted, and your claim is processed as a no-RAP LUPA claim, no penalty will apply. The payment reduction cannot exceed the total payment of the claim.

Requesting an Exception for an Untimely RAP Submission

An HHA may request an exception if the RAP is filed more than 5 calendar days after the period of care. The four circumstances that may qualify for an exception are:

  • Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the HHA's ability to operate
  • An event that produces a data filing problem due to a CMS or CGS system issue that is beyond the control of the HHA
  • A newly Medicare-certified HHA that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from CGS.
  • Other circumstances determined by CMS or CGS to be beyond the control of the HHA.

To request an exception, enter information supporting the circumstance (listed above) that applies to the RAP in the REMARKS field on the Claim (FISS Claim page 04).  For example, if the RAP to a claim was originally received timely but the RAP was canceled and resubmitted to correct an error, enter in the REMARKS field "Timely RAP, cancel and rebill". Add modifier KX to the HIPPS Code reported on the revenue code 0023 line. HHAs should resubmit corrected RAPs promptly (generally within 2 business days of canceling the original RAP).  

If the information provided in the REMARKS field is not clear, CGS will request documentation by generating a non-medical review additional development request (non-MR ADR). HHAs will need to submit documentation supporting the exception request. When a non-MR ADR is generated, the claim will be moved to status/location S B6001. To learn more about how to check for non-MR ADRs, refer to the "Accessing Additional Development Request (ADR) Information" section in the FISS Guide Chapter 3: Inquiry MenuPDF.

Inpatient Stays Spanning the End of a 30-day Period

Discharging the beneficiary is not required if they had an inpatient stay that spans the end of the first 30-day period of care in a certification period. Submit the RAP and claim for the period following the inpatient discharge as if the 30-day periods were contiguous – submit a From date of day 31, even though it falls during the inpatient stay and the first visit date that occurs after the hospital discharge. Refer to MLN article MM11527External PDF for additional information.

Split Percentage Payment

For RAPs with "From" dates on or after January 1, 2020, a split percentage payment is made for the initial and subsequent periods of care. The first payment in response to the RAP is 20 percent. The second payment in response to the final claim is 80 percent.

NOTE: Home health agencies newly enrolled in Medicare on or after January 1, 2019 will not receive split percentage payments beginning in calendar year 2020. Refer to MLN article SE19005External PDF for additional information.

For RAPs with "From" dates on or after January 1, 2021, the up-front split-percentage payment for all 30-day periods of care will be lowered to zero for all HHAs (newly-enrolled and existing).

Canceled RAP Payment

The RAP payment will be canceled automatically by Medicare if the final claim is not submitted 60 days after the calculated end date of the period of care (day 90) or 60 days after the paid date of the RAP (whichever is greater). In addition, in cases when no visits are made during a 30-day period of care, the RAP will be auto-cancelled to recover the payment. See MM11527External PDF for additional information. RAPs with "From" dates on or after January 1, 2021, will not canceled automatically.

RAP Submission Data Elements

Centers for Medicare & Medicaid Services (CMS), Pub. 100-04, Ch. 10, section 10.1.12 and 40.1External PDF

Generally, a RAP and a claim will be submitted for each 30-day period of care. The following provides the data elements required on a RAP. The following table provides the required fields when submitting the RAP via Direct Data Entry (DDE).

RAP Submission Data Elements
FISS DDE Claim Page 01 (Map 1711)

DDE Field Name

Description/Valid Values

MID

Medicare ID – Enter the Medicare Beneficiary Identifier (MBI) number as it appears on the beneficiary's eligibility file. Refer to the Checking Beneficiary Eligibility Web page for details about the applications available to check eligibility.

TOB

Type of Bill – A 4-digit field. Valid values:

  • 0322 – RAP type of bill (TOB)
  • 0328 – Void/Cancel RAP TOB

NPI

National Provider Identifier – Enter your home health agency's NPI number.

STMT DATES FROM and TO

Statement Covers Period "From and To" – Enter the same date for both the "from" and "to" dates. (MMDDYY format)

  • First RAP in an admission, the "from" and "to" date must be the date the first Medicare billable service occurred.
  • Subsequent RAPs, the "from" and "to" date must be the first calendar day of the subsequent period of care.

LAST

Beneficiary's Last Name – Enter the beneficiary's last name exactly as it appears on the beneficiary's eligibility file.

FIRST

Beneficiary's First Name – Enter the beneficiary's first name exactly as it appears on the beneficiary's eligibility file.

DOB

Date of Birth – Enter the beneficiary's date of birth (MMDDCCYY format) exactly as it appears on the beneficiary's eligibility file.

ADDR 1-6

Address – Enter the beneficiary's full mailing address, including street name, number, post office box number, city and state.

ZIP

Zip Code – Enter the beneficiary's zip code of the city and state where they reside.

SEX

Sex – Enter the beneficiary's gender using the applicable alpha characters.
M – Male; F – Female

ADMIT DATE

Admission Date – Enter the date the beneficiary was admitted to home health care. (MMDDYY format)

  • First RAP in an admission; this date should match the statement covers "from" date.
  • Subsequent RAPs in a period of continuous care; this date should remain constant, showing the actual date the beneficiary was admitted to home health care.

SRC

Source of Admission – Now referred to as the Point of Origin. Valid values:

1

Non-health care facility point of origin

2

Clinic or Physician's office

4

Transfer from hospital (different facility)

5

Transfer from skilled nursing facility (SNF) or intermediate care facility (ICF)

6

Transfer from another health care facility

8

Court/Law enforcement

9

Information not available

The above codes represent those most frequently submitted on home health RAPs/claims. A complete listing of all codes is accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications ManualExternal Website

STAT

Patient Discharge Status – Enter the patient status code 30 (still a patient).

COND CODES (conditionally required)

Condition Codes – Enter any NUBCExternal Website approved code to describe conditions that apply to the RAP.

  • If the RAP is for a period of care in which the patient has transferred from another home health agency, enter condition code 47
  • If canceling the RAP (TOB 0328), enter a condition code indicating the appropriate claim change reason. Enter your reason for cancellation in the "Remarks" field (FISS pg 4).

FAC. ZIP

Facility Zip Code – Enter the 9-digit zip code of the provider or the subpart.

VALUE CODES

Value Codes and Amounts

Optional for "From" dates on or after January 1, 2021. See MM11855External PDF for additional information.

Required for "From" dates prior to January 1, 2021.

61 – Enter 61 and the appropriate Core Based Statistical Area (CBSA) code that corresponds with the location where the service is provided at the end of the period of care. Access the Home Health Payment Rates Web page for these calendar year codes. NOTE: Value code 61 is optional for RAPs with "From" dates on and after January 1, 2021.

85 – Enter 85 and the associated Federal Information Processing Standards (FIPS) State and County Code in which the home health service was furnished. Refer to the CMS' SSA to FIPS State and County CrosswalkExternal Website information to access the FIPS State and County Code. NOTE: Value code 85 is optional for RAPs with "From" dates on and after January 1, 2021.

Note: When entering a value code that represents a number rather than a monetary amount, enter the number followed by two zeros. For example, to indicate a CBSA code 99916, the number would be keyed as 9991600 or 99916.00.

RAP Submission Data Elements
FISS DDE Claim Page 02 (Map 1712)

DDE Field Name

Description/Valid Values

REV

Revenue Code – Enter the revenue code 0023 to report the HIPPS code. No other revenue codes are required on a RAP.

HCPC

Healthcare Common Procedure Coding – Enter the HIPPS code in this field (HHRG from the OASIS). The HIPPS entered may be any valid HIPPS code for billing; the actual HIPPS code for payment will be determined by the Medicare system.

SERV DATE

Service Date – Enter the date of the first covered service provided. For subsequent periods of care, report the date of the first visit, regardless of whether the visit is a covered or noncovered visit.If the plan of care dictates multiple 30-day periods of care will be required to effectively treat the beneficiary, you may submit RAPs for both the first and second 30-day periods of care, for a 60-day certification or recertification, at the same time. For subsequent RAPs, with "From" dates on and after January 1, 2021, submit the first day of the period of care as the Service Date on the 0023 revenue code line.

When No Visits are Expected: In cases when no visits are expected during a 30-day period of care, submit a RAP for all 30-day periods with the first day of the period of care as the service date on the 0023 line.

This will ensure the HHA is shown on the Common Working File (CWF) as the primary HHA for the beneficiary and will ensure that HH consolidated billing is enforced. (Reference: MM11527External PDF).

RAP Submission Data Elements
FISS DDE Claim Page 03 (Map 1713)

DDE Field Name

Description/Valid Values

CD

Primary Payer Code – Enter "Z" for Medicare
NOTE: RAPs should always be submitted as Medicare primary regardless of any Medicare Secondary Payer situation.

PAYER

Payer – When "Z" is entered in the CD field, FISS will automatically insert the payer name "Medicare" in this field.

RI

Release of Information – Enter the appropriate valid value:
Y – Provider has on file a signed statement permitting the provider to release data to other organizations
R – The release is limited or restricted
N – No release on file

DIAG CODES

Diagnosis Codes – Enter the appropriate ICD code for the principal diagnosis code and any other diagnosis codes for conditions that coexisted when the plan of care was established. Other diagnosis codes are optional for RAPs with "From" dates on and after January 1, 2021.

Note: The claim and OASIS diagnosis codes will not be expected to match in all cases.

ATT PHYS
NPI, L, F, M

Attending Physician – Enter the NPI and name (last, first name required, middle initial optional) of the attending physician that established the plan of care with verbal orders.

RAP Submission Data Elements
FISS DDE Claim Page 04 (Map 1714)

DDE Field Name

Description/Valid Values

REMARKS

Enter a remark when canceling the RAP (0328 TOB) to indicate the reason for the cancellation.

RAP Submission Data Elements
FISS DDE Claim Page 05 (Map 1715)

DDE Field Name

Description/Valid Values

INSURED NAME

Insured Name – Enter the patient's name as shown on the Medicare card.

CERT/SSN/MID

Medicare ID – Enter the Medicare Number as it appears on the Medicare card if it does not automatically populate.

TREAT. AUTH. CODE

Treatment Authorization Code – Not required under PDGM.

Updated 02.15.21

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